Provider Demographics
NPI:1467447946
Name:KLOSE, THERESA D
Entity type:Individual
Prefix:MS
First Name:THERESA
Middle Name:D
Last Name:KLOSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3181 OLD MILL RUN
Mailing Address - Street 2:
Mailing Address - City:MILLBROOK
Mailing Address - State:AL
Mailing Address - Zip Code:36054-2810
Mailing Address - Country:US
Mailing Address - Phone:334-290-1826
Mailing Address - Fax:
Practice Address - Street 1:700 TWINING STREET
Practice Address - Street 2:
Practice Address - City:MAFB
Practice Address - State:AL
Practice Address - Zip Code:36112
Practice Address - Country:US
Practice Address - Phone:334-953-5143
Practice Address - Fax:334-953-8296
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1494133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered